Symposium: What would Hippocrates do?

Frank Trinity is the chief legal officer of the Association of American Medical Colleges. The AAMC filed an amicus brief opposing the government’s stay applications in Trump v. IRAP and Trump v. Hawaii.

Why, you may ask, are America’s medical schools and teaching hospitals involved as “friends of the court” in the travel ban case?

The answer begins with the fact that our nation relies upon a significant number of physicians, scientists and other health professionals from foreign countries to care for patients, address health-professional shortages and contribute to breakthroughs in biomedical research. Over the past several decades, Congress has established multiple pathways to attract highly-trained professionals, provided that their backgrounds and qualifications are carefully screened. More than one in four practicing physicians were born in another country. Many of these physicians practice in rural and other underserved areas. Last year, all six American winners of the Nobel Prize in economics and scientific fields were immigrants. Since 2000, immigrants have been awarded 40 percent of the Nobel Prizes won by Americans in chemistry, medicine and physics.

As a matter of policy, then, barring or discouraging health professionals from coming to the United States could set back cutting-edge research and exacerbate a growing shortage of physicians, nurses, mental-health professionals and dental-health professionals, particularly as the number of older Americans increases in the decades ahead.

But the answer runs deeper. In 2010, shortly after joining the Association of American Medical Colleges, I attended a presentation on a medical regulatory issue. The presenter – a nationally known physician – began with several slides about medical ethics, and pushed the audience of several hundred medical-school faculty members to apply principles from the Hippocratic Oath like “effacement of self interest” and “do no harm” in approaching the issue. The balance of the session focused on research findings, studies of how different approaches to the issue would affect patient care. I was struck by the deep and palpable application of ethical principles and rigorous scientific inquiry to nearly every facet of medical care, at a breadth and depth I had not experienced previously. Such was my introduction to academic medicine – teachers, practicing physicians and physician-scientists – passionately focused on a three-part mission of education, clinical care and research.

When the first travel ban was announced at the end of January 2017, word spread of physicians, researchers and other health professionals being denied entry into the United States. Additionally, the annual “Match” was only weeks away. The Match is a process by which medical school graduates from around the world learn whether and where they will begin their U.S. medical residency, the final step in becoming a licensed physician in the United States. More than 35,000 medical-school graduates applied to more than 28,000 residency positions in more than 4,000 first-year residency programs. Applicants included medical-school graduates from the seven affected countries. Although some programs, like Rush University Medical Center, publicly stated that they would rank candidates without regard to country of origin, there was great concern that other programs would skip over otherwise qualified physicians. We still don’t know all the details, but it appears that the lower courts’ injunctions against the first travel ban may have saved the integrity of the 2017 Match.

The second executive order did little to ease our concerns, particularly about its potential impact on teaching hospitals. Teaching hospitals serve as our country’s safety net for treating low-income patients. They are trusted to care for the most difficult cases such as trauma, burns, and pediatric intensive care, and have shown their value in treating victims of the Boston Marathon bombing and the highly contagious Ebola virus. Teaching hospitals rely heavily on physicians and other health professionals from around the world, and therefore depend on fair and predictable visa and other immigration processes. Sudden exclusions or backlogged visa processing present an acute risk to the ability of teaching hospitals to provide high-quality care. Even short-term barriers and delays will immediately strain coverage in critical care, surgical and outpatient settings.

Facing the prospect of gaps in our ability to provide care and conduct biomedical research – and applying the ethical imperative to put patients first – the AAMC felt compelled to articulate the direct connection between fair and stable immigration processes and our nation’s health security. No one questions the federal government’s responsibility to safeguard our country from terrorism, but we also believe that our nation’s health security is served by a vital healthcare workforce, scientific collaboration and the promotion of medical progress. On a day-to-day basis, we work with various government agencies to address medically underserved communities (as designated by the Department of Health and Human Services), ensure that veterans have access to care at Department of Veterans Affairs health-care facilities, respond to emerging public health crises such as infectious diseases, and support the efforts of our military to provide the best battlefield-injury care to members of our armed forces. If the world’s most highly skilled health professionals find pathways to the U.S. unavailable or unwelcoming, patients here will be hurt first.

Because the travel-ban injunctions involved issues of harm, the public interest and weighing of the equities, the AAMC decided to submit an amicus brief urging the Supreme Court to maintain those immigration pathways while it considered the merits. Joined by 21 other health-related organizations, we endeavored to inform the debate from our professional perspectives.

We are pleased that the Supreme Court allowed for continued entry by individuals with connections to U.S. schools and employers, which should maintain our healthcare workforce’s ability to deliver care and undertake discovery without disruption while the case is pending. Over the longer term, we will continue to press for a decision that safeguards the health of Americans.

Now that the Supreme Court has moved beyond the stay applications, we realize that it has less flexibility to make a decision principally on the equities involved. But we remain hopeful that those involved in the debate about our nation’s security and our nation’s values will pause to consider the benefits to our country associated with the free exchange not only of ideas and ideals, but also the people who express and embody them.